When the organization is a problem: an empirical study of social work with substance use problems in more or less NPM-influenced Swedish municipalities

ABSTRACT

New Public Management (NPM) has added new aspects to the conflict between political-bureaucratic steering and professional autonomy in the search for a substance use treatment system (SUT) that is economic and characterized by high quality, accessibility, and professional discretion. This article analyses if and how organizational aspects of NPM imply additional challenges for professionals and SUT. The experiences of 29 social workers, in different positions in the services and administration of SUT, in six municipalities with different degrees of NPM and post-NPM, form the empirical data. Many quality problems were common across municipalities: frequent unevaluated reforms, lack of resources for SUT, and cooperation issues. Several problems were especially pronounced in statutory social work. NPM added challenges. Competition with private providers was viewed as initially (in the 1990s) having improved treatment, but the present market was regarded as creating quality problems without savings. Cooperation between providers was a special quality challenge in NPM municipalities, and NPM added to treatment continuity challenges. While accessibility for resourceful clients was linked to NPM models, treatment for less resourced users was obstructed by NPM. Workplace climate and trust issues were more problematic in the most NPM-permeated municipalities. Professional discretion was difficult to link to local NPM degree. Increased standardization and documentation were often accepted as improving quality. While a system based on competition ideology appeared destructive for treatment quality, post-NPM reforms with cooperation between needs-assessment, treatment, and economic support, conformed better with professionals’ perceptions of good treatment.

KEYWORDS:

• Substance use treatment
• professionals
• New Public Management (NPM)
• post-NPM

Introduction

Social work has always been politically and bureaucratically regulated to attain specific agreed goals of both integration and social control of vulnerable individuals (Dellgran 2016), regulations necessary for predictability and universalism. On the other hand, it is acknowledged that social workers must have a certain discretion, based on professional competence, to make decisions on complex and individual problems. This discretion must be built on legitimacy and trust from the political and bureaucratic levels, based on beliefs in the knowledge and values of the staff. It can be argued that the organization of social work is conservative, due to these combined tasks, which require political and bureaucratic insights (Lundström and Sunesson 2016), and that social work has always been characterized by inevitable conflicts between the organization (and its resources) and professional ideals (Dellgran 2016).

Research has claimed that New Public Management (NPM) has added new aspects to this conflict between political-bureaucratic steering and professional discretion (Hjärpe 2017; Tham 2018). NPM remains rooted in neo-liberalism, an ideology where entrepreneurship, private property rights, and free market are the primary means towards well-being and the state is an enabler of these conditions. Definitions of the fluid concept NPM include competition between providers in (tax-funded) services, strict limits for expenditure and emphasis on measurable outputs rather than results of functioning processes (Hood 1991). The model includes use of time-limited contracts, sometimes internal markets in the public administration, and an emphasis on delineated and individual responsibilities in contrast to a focus on responsibility for the common good (Hanssen et al. 2015; Pollitt, van Thiel, and Homburg 2007). Users change from being citizens to becoming customers.

Organizations built up around NPM ideals may thereby lead to conflicts with core values of social work, as defined by the IFSW (International federation of social workers 2014): social justice, human rights, empowerment, social cohesion, respect for diversities, and collective responsibility for welfare (Hanssen et al. 2015; Spolander, Engelbrecht, and Pullen Sansfaçon 2016). From public health and SUT point of view, the crucial questions are whether marketization enables a treatment system that is economic in its use of public money, is of high quality, defined as accessible, coordinated, with continuity, and thus can properly meet the needs of a diversified clientele (Babor, Stenius, and Romelsjö 2008).

Research has pointed out that NPM can have some benefits – e.g. better control of the treatment offered (Commons, McGuire, and Riordan 1997), more economic service production (Maynard, Street, and Hunter 2011), and client empowerment (Andersson and Johnson 2020). However, new conditions and paradoxes arise as the commodification of treatment moves managers and professionals into a ‘twilight zone’ between the public and the private (Bjerge and Bjerregaard 2017). Problematic impacts on social work with NPM can be the results of a mechanical economization, e.g. frame agreements following public procurement which may restrict treatment decisions (Storbjörk and Samuelsson 2018). New routines and increasing measurements potentially restrict holistic and individualized social work (Hjärpe 2017; Lauri 2016). Competition within the municipality or between providers may conflict with the need for multi-agency and multi-professional cooperation to solve complex problems and continuity in services (Nesvåg and Lie 2010). Furthermore, political values stressing individualism and personal responsibility instead of social rights and collective needs, can be a challenge for public health or welfare perspectives (Beck and Beck-Gernsheim 2002; Hanssen et al. 2015).

In response to these challenges and NPM’s emphases on efficiency, control, and narrow responsibilities, post-NPM reforms and philosophies have sought to attenuate the problems or even replace NPM by various coordination and cooperation improvement efforts; re-centralization and functional or horizontal re-integration; partnerships; and by encouraging values such as equity, citizenship, and democracy (including re-politicization and political accountability). ‘Post-NPM’ is becoming increasingly institutionalized, but this umbrella concept appears to be equally fluid as NPM (Reiter and Klenk 2019). The boundaries between NPM and post-NPM remain blurred in real life and the organizations become increasingly layered with added reforms (Wällstedt and Almqvist 2015). Klenk and Reiter (2019) note a high congruence between post-NPM and traditional values or features of social work.

Substance use problems remain primarily conceptualized as social problems in Sweden, and as a municipal social service responsibility. According to the Social Services Act, the municipality is obliged to provide support and help to individuals in accordance with their needs. Social workers have the central role in municipal SUT, both in the assessment of treatment needs and in the delivery of especially outpatient services. Withdrawal and medical/psychiatric conditions are treated in the regional-level medical system responsible for pharmacotherapies.

Since the 1990s, SUT in many Swedish municipalities has increasingly been steered through local public procurement, often within local purchaser-provider-models in the municipal organization and today with a large share of contracted private for-profit providers (Storbjörk and Stenius 2019a). Other features of NPM, often linked to output control in the NPM spirit, are the introduction of registration of interventions, evidence-based practices (EBP), standardization of services and procedures, and various national or local guidelines for treatment and documentation (Eriksson and Janlöv 2020; Hanssen et al. 2015; Hjärpe 2017; Lauri 2016). Many of these have been reinforced by national policies and bodies with the duty to control local performances. Most Swedish municipalities will thus have experienced some NPM features, but in different degrees and more or less recently implemented.

Still, the local variations in the organization of social services, including SUT, are big. Furthermore, NPM or post-NPM as sets of organizational features and working principles always coexist with previous models (Reiter and Klenk 2019; Wällstedt and Almqvist 2015). Administrative reforms in general and NPM in particular remain astonishingly understudied in the SUT research literature (Storbjörk and Stenius 2019b), despite the fact that the needs of SUT rarely drive local reforms and its service users typically have the weakest voice. It remains unknown to what extent NPM really shapes the municipal SUT and whether certain NPM features create specific conflicts between the organization and professional social work.

Therefore, the primary aim of this article is to empirically explore in detail if and in what way, according to social workers in SUT, organizational aspects of NPM imply special challenges for good quality care and professional social work with substance use problems. Due to the complexity of organizations in real life, it also indicates challenges that are shared with other social work areas and organizations. The article is largely embedded in a comparative qualitative method. We use an extensive qualitative data material including social work managers and frontline professionals’ experiences and perceptions of a range of organizational features and analyse how these are linked to established SUT quality criteria and core values of social work of importance for dealing with complex problems of a diversified clientele (see above). We seek to distinguish the impact of central NPM features from those that are common with traditional welfare models and organizational qualities conceptually associated with post-NPM. These varied data and procedure can thereby offer a realistic real-world account of potential challenges added by NPM, and guide future reforms.

Methods

The article draws upon a larger research project on the organization, steering and daily practices of social services-based and medical SUT with special emphasis on the permeation and experiences of NPM in six municipalities (out of 290) and three regions (of 21) of Sweden. The background, setting and central actors (government agencies, local-level politicians and responsible political boards, local administrations, and private providers), as well as detailed elaborations on the different qualitative and quantitative data sources, sampling procedures, interview guides, and characteristics of chosen municipalities/regions and interviewees are disclosed in a full-length open access report (Storbjörk, Antonsson, and Stenius 2019). The project used informed consent. Research participants were confidential – hence the lack of overly detailed information about the municipalities. The project received ethical clearance by the Ethical Review Board of Stockholm (EPN 2016/446-31/5).

The data set used in this article is delineated to interviews in the six municipalities chosen to offer sociodemographic and organizational diversities central to SUT. As a concern for sociodemographics, we sought heterogeneity in preconditions such as size, wealth, and local political majority. SUT, social work, and organizational choices, are politically governed activities that may be influenced by local political traditions. As for organizational heterogeneity, we strived for diversity in NPM features and permeation. There is no compiled information on local organizations, but the initial mapping demonstrated several NPM features central to SUT: high degree of purchased privately produced services as opposed to inhouse public provision; competition in the public administration (more or less advanced purchaser-provider models and split responsibilities); high reliance upon public procurement, e.g. framework agreements, or even voucher systems with accredited providers; performance-based funding; and auditing via standardized systems, e.g. Lean. We included municipalities that had implemented some or several of these. Next, the municipalities were ordered from NPM-1 to NPM-6 according to NPM-permeation. NPM-1 almost lacked such features, there were some features in NPM-2 and NPM-3, a tradition of high permeation but with signs of moving towards post-NPM in NPM-4 and NPM-5, and continuously high NPM permeation in NPM-6. These are further described below.

This article relies upon the 29 semi-structured interviews, covering 34 employees (5 interviews included 2 interviewees), conducted by the second author (March 2017–June 2018), with social work managers, staff exercising statutory public authority in assessing needs and granting treatment, and other frontline professionals working with municipal outpatient treatment or support (e.g. housing). Purposeful and snowball sampling were applied, as we first in collaboration with initial local contact persons sought to identify those that could give accounts of either the organization and reforms or/and how it impacted on the daily practices. As the fieldwork proceeded and we noticed gaps in our understanding of each organization, we asked our informants for others to approach. We also noticed differences in daily practices between experienced and newly graduated professionals and therefore always sought to recruit both types, even if we initially were often presented with more senior ones.

All interviews were transcribed and thereafter read by the authors. While initially coding the voluminous text material in QSR NVivo, the second author made summaries of each interview to ease comparisons. These summaries formed the bases for the first exploration of the data set. This step sought to identify relationships between how informants talked about aspects related to good quality SUT and social work (e.g. economy, cooperation, continuity, accessibility, respect for diversities and equity, discretion, Babor et al. 2008; ISFW, 2014) on the one hand, and organizational features and reforms on the other (e.g. competition). The links could either refer to professionals’ own statements regarding how organizational aspects influenced daily practices or be grounded in the problems typically raised by informants in a municipality characterized by certain NPM features. Besides comparing experiences across municipalities high-low on NPM, the views of social workers in statutory social work and other treatment/support units were also compared, the reason being that statutory work is clearly more regulated by legislation and bureaucracy than therapeutic interventions. Next, the full transcripts were re-read to further refine and nuance patterns identified, e.g. with the purpose of distinguishing between problems that perhaps were more clearly linked to the administration size or the work experience of the informant than to certain market features. This step also included the effort to try and distinguish between aspects of daily practices that are related to NPM, in relation to features present also in more traditional welfare organizations.

First, we present the general municipal organizations. As we shall see, they are all, as expected, in some sense hybrid or layered organizations, with traits of traditional welfare organizations and NPM and post-NPM characteristics. This complication frames and enriches the analyses. The analysis continues by comparing the experiences of how the organization impacts on the welfare or public health goals for treatment: views on whether the organization promotes an economical use of services, and views on quality and resources, i.e. on coordination of and continuity in services, and on accessibility and equity of services. Finally, we look at the social workers’ sense of autonomy.

Supplemental online material presents examples of short quotes from the interviewees in the six municipalities to support our conclusions and demonstrate that the analysis is not based on a few or selected interviews.

The municipalities: six hybrid and four moving municipal organizations

Concerning NPM permeation, two municipalities had no internal market, and no emphases on market models, such as public-private competition or privatization of public services. Both had left-wing political majorities. Two municipalities had experiences of market-like steering but with a clear presence also of traditional welfare steering models and a protection of public provision, favouring inhouse treatment. Two municipalities, with right-wing majorities, had strong emphases on competition, outsourcing, and stressed market models as a route to better services. Notably, one municipality in the first group was introducing more market-like features, and one in the middle group and one in the last group were moving away from internal market models. This illustrates how treatment systems research is always dealing with moving targets. It also echoes research (Storbjörk and Stenius 2019a), demonstrating how purchasing of private services first was implemented in right-wing municipalities, but how this had become ‘the new normal’, and how more recently left-wing Swedish municipalities increased their purchasing more than right-wing ones.

It was only in the smallest and least NPM-influenced municipality (NPM-1) that social workers reported no restrictions of their professional work that originated in the municipal organization of SUT. This municipality was also one of the two municipalities (the other one NPM-6) that did not at the time of the interviews go through any reforms. NPM-1 has a small bureaucracy, with close and reportedly good cooperation between staff with different tasks. In all other municipalities, the organizations were in some ways conceived as problematic.

In the municipality NPM-2, social services were to be reorganized, separating statutory work from treatment, within the same budget, and moving economic support to another section. This kind of ‘quasi purchaser-provider organization’ will give the statutory part the role of assessing treatment needs that bind outpatient treatment. Inhouse outpatient services were and will be prioritized.

NPM-3 is a fairly big municipality where municipal statutory measures and treatment were investigated to be separated, still within the same budget, keeping the focus on inhouse outpatient treatment provision. Statutory work would focus on needs assessment and ordering, and outpatient treatment on providing ordered care.

NPM-4 was, in contrast, moving away from an internal market that had separated statutory addiction work and treatment into different boards with separate budgets, towards integration of these activities and budgets. NPM-4 would anyhow keep the competition and outsourcing for some outpatient services. Outpatient treatment shall be favoured.

In the fairly big municipality NPM-5, statutory measures and treatment had been handled in separate boards with separate budgets (internal market). At the time of the interviews, they were reorganizing to be united. Economic support was situated under a third board and would still, after the reform, be separate from SUT.

In municipality NPM-6, the one with the longest and most systematic NPM-permeation, no administrative reforms were planned. The organization was highly specialized, with a clear separation of statutory work, treatment and economic support into three different parts, under three different boards and budgets, and a focus on citizens as customers, impacting on services through their own choices. This was the only municipality where there was no declared priority to use outpatient treatment.

In sum, all municipalities but NPM-1 would be either changing into NPM-like organizations, moving away from such an organization, or, like NPM-6, still being in one. This means that many of our interviewees were able to compare experiences of more traditional welfare organizations and more market-influenced ones. Many interviewees had also worked in other municipalities or service areas, which further enriches the study. Next, we analysed views on how different aspects of treatment organizations impact SUT.

Economical organizations?

In municipal distribution of tax resources, SUT has often been a service branch where costs have been questioned by decision makers. The problems have sometimes been viewed as caused by the user themselves, they are prone to be stigmatized, and thus not prioritized. The interviews showed that the political desire to keep costs down was often prominent behind internal guidelines and reforms, both reforms that increased NPM and moved towards post-NPM. We wanted to analyse further if the significance of economic frames differs by NPM permeation, and if they imply different restrictions on the work with substance use related problems in different settings?

Social workers in NPM-1 (Statutory workers (Stat), two persons), that did not conceptualize their own organization as market-like, worried about the increasing prices for purchased residential care unavailable inhouse, caused by procurement. They regretted that they were personally required to negotiate prices when looking for suitable residential treatment. In general, however, they felt they had good support within the administration and from the law and national bodies to suggest appropriate treatment, even when the board suggested cheaper solutions. Here the economic conflict was manifested as one between professional needs assessment and the municipal budget.

In the rich NPM-6 ‘money is not mentioned’: decisions are ‘based on individual needs assessment’ (NPM-6, Stat. head of group), sometimes even on the clients’ explicit choices of providers, and inpatient treatment is relatively common. In all other municipalities, the economic frames did put obvious restrictions on the treatment choices.

All municipalities except NPM-6 reported that inhouse outpatient treatment was a priority in the municipality. This priority was in general supported by the staff, even if the prime political motive might have been economy – avoidance of more expensive, purchased institutional treatment.

Sometimes, however, the requirement to prioritize outpatient treatment was regarded as irrational. In NPM-2, the staff reported that they had to choose the least expensive measures, which could be inefficient in the long run. In municipalities NPM-3 to NPM-5, staff reported that savings had resulted in a lack of staff and a too large work burden, with shorter treatment periods, and too little purchased treatment, especially towards the end of the year. ‘I hope they see that the bottom has been reached – it is impossible to save any more’, said one of the interviewees (NPM-4, OutPatient (OP)).

However, overall, it is difficult to say that NPM permeation alone was directly associated with less financial resources for treatment. The general economic situation of the municipality and political tradition played a crucial role.

From a system point of view, an economic organization is one that uses available resources in the best way, considering the system’s goals. The national goals in this case are set by the Social Services Act and other care legislation: to provide treatment according to the needs of the clients. Competition on a market is by NPM advocates viewed as something that can lower the prices of requested services without affecting the quality and thus result in more economic organizations.

None of our interviewees mentioned, however, any savings as a result of marketization or privatization. On the contrary, in both municipalities NPM-1 and NPM-2, it was estimated that the marketized development in Swedish SUT had led to higher prices, through the formation of cartels and through procurement and other administrative processes. In NPM-6, one of the interviewees with experiences from municipalities with different organizational models doubted strongly that the NPM organization implies any savings.

Procurement seems in our interviews to be a practice that can have problematic consequences in terms of economic use of resources. It has been driven too much with a focus on short-term savings and with insufficient consideration for the long-term effects of organizational instability. From the treatment perspective, too often costs weigh more than quality in procurement. ‘Maybe purchasing-providing is not totally out of the game, but it should be more strictly controlled … – one cannot save any more, what we need is cooperation’. Procurement and purchasing-providing systems have over time led to a streamlining of all services, meaning less of the ‘little extra’ in individual encounters that can be important for clients (NPM-4, OP). Changes in providers with new contracts are today driven by intentions to save money, with quality loss in treatment and increased discontinuity for service users (NPM-5, Stat. group heads, 2 persons).

The relation between competition and quality is complicated. In municipalities NPM-3 to NPM-6 interviewees mentioned competition as a principle that when first implemented had improved the municipalities’ own treatment. ‘[Competition] can prevent the municipality from falling asleep’ (NPM-3, OP). It has improved the insight both into purchased but also into municipal treatment and stimulated quality improvement and cost-consciousness in outpatient treatment (NPM-5, OP head; NPM-6 Stat. head). In municipality NPM-4, with experiences of internal markets and competition dating back to the early 1990s, one interviewee believed that the first purchaser-provider experiences and competition between municipal and private providers were fruitful for the development of SUT and increased the quality, and that private providers in general were more interested in providing good quality for the clients (NPM-4, Stat.). However, another interviewee in the same municipality claimed that things had changed since the 1990s: today’s private providers are driven too much by profit-seeking, without any idealism. ‘Today’s private providers don’t necessarily focus on quality’ (NPM-4, OP, head). Preferably, according to this interviewee, all services should be provided by the public sector, but with cost consciousness.

There are several mentions of how outsourcing and privatization of previously public services have implied a destruction or decline of the quality of treatment services. A change of provider, from public to private, stopped an important coordination and development processes in the organization and the private company has lowered the standard, have less staff and do not care about treatment guidelines. No evaluation of the effects of changes of providers is performed (NPM-4, OP). There is in general too little insight into the activities of private providers. They have taken on tasks that they are not ready to handle, leading to less good services for the clients (NPM-4, OP; NPM-5, OP). Privatization of former public services had in some cases resulted in a stripping of the resources of units, which the municipality in the end had to compensate for with increased costs and a loss of competence. In the end, municipal treatment stands for security and has to step in when things go bad, even take back some privatized units (NPM-5, OP).

Cooperation in conflict with NPM but also neglected in other reforms

The need in SUT for cooperation between different service providers is stressed but a challenge in all study municipalities. Problems in the cooperation between municipally financed treatment and SUT within health care are mentioned everywhere. They seem to be common not least due to the prevalence of co-morbidity. There are problems with the lack of resources for detox, which some municipalities (e.g. NPM-1, NPM-2, NPM-4) have tried to counter-act by contributing financially to this health care responsibility, or with the region not partaking in required treatment conferences. Other problems are linked to the different organizations in social work and health, respectively, including the obstacles for sharing registers. In the very market-oriented NPM-6, an interviewee at the outpatient unit noted that the region’s organization had a more developed purchasing-providing model and payment for performance, resulting in continuous changes of staff and providers and thus repeated cooperation problems – it takes years to establish day-to-day routines and it requires continued work to maintain such cooperation (NPM-6, OP).

In moderate sized or big municipalities, specialization within the social services is inevitable. For instance, a separation between statutory work, on one hand, and actual provision of treatment on the other can be good: ‘otherwise the investigations/assessments will be prioritized, and treatment will have to make way’ (NPM-5, Stat. Head of group). When the problems of the individual are complex, appropriate treatment requires cooperation between the statutory units, between the various municipal or purchased units, between treatment and those providing economic support, between SUT and child care units, SUT and vocational training, etc.

Our data show that organizational reforms attempting to improve cooperative obstacles, for instance between statutory work and treatment, however, often are at risk of leading to new obstacles, when they imply new boundaries As stated above, in four of the six municipalities reforms had just been implemented or were decided. In all but one, the staff complained that the reforms had been decided without proper evaluation of the previous system, without sufficient information about the reasons for the changes, and/or too quickly. From the staff’s point of view, decisions were made without proper knowledge about the daily client work.

One attempt to minimize the need for time-consuming and expensive work in complex organizations is to give detailed instructions about the limits of the tasks of various units, e.g. order statutory social work to try outpatient treatment for all clients, which was the case in municipalities NPM-2 to NPM-5. If this recommendation is too rigid it will, however, lead to problems. And as the interviews show, it is not uncommon that statutory workers and outpatient staff have different views on treatment needs of single clients. In the end, then, ‘it is a question of communication if (statutory’s) cooperation with outpatient works’ (NPM-4, Stat.). This communication appears to require a feel for the situation to know when to interfere and when to accept others’ decisions in individual cases (NPM-3, Stat).

As local outpatient treatment today, in most of the municipalities, is anyhow viewed as the best option for most clients, close cooperation between statutory social work and outpatient units is particularly crucial for coordination. The interview data show that social workers prefer everywhere an organization where statutory work and outpatient treatment is handled within the same budget and under the same political board and administrative leadership, preferably even, according to several interviewees, sitting in the same building. In NPM-1 this is the case. In NPM-2, the coming reform will separate the two, which is expected to lead to an increased distance between different sides in SUT. In NPM-3, where the two are in the same board/budget, there are sometimes disagreement between statutory side and outpatient, but on both sides, interviewees report good cooperation. In NPM-4, where they are joining outpatient and statutory work again under the same board, and leaving the internal market model, the expectations are better cooperation and less conflicts about treatment needs. ‘Now we will work hand in hand with statutory work … a united front [in relation to the board]’, ‘the treatment decisions will be quicker’ (NPM-4, OP), and it will be a ‘joint responsibility’ to solve the clients’ problems (NPM-4, Stat.) as opposed to the previous situation in which they sometimes ‘did not have the client in focus’ and almost ‘argued [internally] about who should pay for what’ (NPM-4, Stat. head). In NPM-5, where the organization has separated purchasing and provision most of the interviewees are unsatisfied with the cooperation. Also, in the marketized NPM-6 the lack of trust and communication between different units is described as a problem.

One NPM attempt to enhance efficiency is to increase the steering and control of time use. In one municipality (NPM-2), otherwise without much NPM features, a detailed planning and reporting system of activities minute for minute was about to be implemented in outpatient treatment, against the strong will of the staff. But it was not only in this municipality that the staff argued that an increased focus on counting volumes and quantity was an overall and deteriorating trend in SUT. ‘They record number of treatment plans, number of occupied beds, the length of treatment … but what is the added value of this for the clients?’ asked one outpatient worker (NPM-3, OP). In another, despite higher aspirations treatment providers had to settle with ‘good enough’ as superiors emphasized the client flow (NPM-4, OP).

In the two most NPM-like municipalities, one moving towards post-NPM and one with a purchaser-provider system in force, economic support was organizationally separated from SUT. The intention is specialization, to save time for treatment decisions and provision. The majority of the clients need, however, economic support and if the economy units cannot share the information about the client with the other units or regard the issue as a strictly economic matter they can in fact with a negative decision complicate SUT significantly.

Cooperation across organizational borders seem to be a special challenge in the municipalities with most NPM features. In NPM-5, the distance between statutory work and outpatient has been very strict. For statutory work this implied lower status: lower salaries, less experienced staff, overloaded staff, with no time for cooperation, structured work or necessary routines, and in general a problematic workplace atmosphere. It created a gap between the two parts of SUT (NPM-5, Stat. heads of group). General lack of trust and knowledge about the others’ is sensed in the more NPM-like organizations and most clearly raised in NPM-6: ‘Every unit is like an independent corporation. There is no trust within the organization’ (NPM-6, OP). ‘It is difficult to develop social work when we do not talk to each other. You have imagined pictures of others [in the organization] that do not correspond with reality … You work with the same things, but in competition’ (NPM-6, OP).

A separate question is the cooperation between municipal authorities and private contracted providers. All municipalities are used to purchasing residential treatment, some purchase housing or outpatient services. Problems in this cooperation are reported regarding lack of shared registers and problems in cooperation between different providers within a treatment chain, but in one municipality an experienced statutory social worker reports that private providers have become better in reporting back (NPM-6, Stat). The problems with these contacts, as reported by interviewees, are mostly linked to procurement and contracts.

Continuity broken by reforms, insufficient funding and short and rigid contracts

We have already mentioned disturbed established cooperation by frequent and abrupt reforms, and treatment discontinuity is identified as a problem in most of the municipalities. ‘There are problems both in the organizational model and in the procurement. Especially for those who have big problems it is very important to keep the providers’ (NPM-5, Stat. head).

Municipal staff turnover is a discontinuity problem mentioned in all municipalities, except NPM-1. This phenomenon is linked to a lack of budget funding, or unreasonable workload, causing sick leaves and a vicious circle where it becomes hard to recruit new staff. The result can be ‘a loss of clients but also of competence’ (NPM-4, Stat.). Budget cuts seem to hit statutory work more immediately than outpatient treatment. The statutory work is also more characterized by routines, implementation of new techniques for reporting, inspection, and may also be more affected by organizational changes that per se can cause stress. Such discontinuities and staffing problems are, notably, not reported by outpatient treatment interviewees.

Discontinuity linked to procurement and contract with non-public providers is a special problem. Both in municipalities NPM-4 and NPM-5 there were complaints over the fact that the last procurement processes implied new providers of important services and loss of (staff in) good housing units or of good treatment institutions (NPM-4, OP and St; NPM-5, Stx2). In NPM-6 concerns were raised over the change of medical SUT provider in a joint municipal-regional unit. The motive for keeping outpatient treatment inhouse in NPM-4 and NPM-5, despite vast marketization, was indeed to ease collaboration with the region. It was not considered feasible to disrupt such collaboration by frequent changes in municipal providers. Sometimes the change of providers can be dramatically sudden: in one case the contract involving long-lasting client contacts moved from one provider to another in a few hours, and the lack of proper and well-prepared handover was raised as a problem in NPM-5.

Continuity in treatment is not only challenged by short and changing contracts. If the contract is very rigid this can also be a problem for continuity in treatment. Treatment needs can change quickly. It is much easier to change the focus of municipal treatment than to re-negotiate a contract with a private provider (NPM-5, Stat. heads). Municipal treatment thereby appeared to serve as a buffer to manage changing needs in organizations strictly regulated by contracts.

Accessibility and equity

The politician’s role is to ensure that treatment is accessible to those in need, and acceptable for all citizens (equity principle). Many interviewees have a critical view on politicians: they are uninterested in treatment, too distant from daily practices, without a longer or with a too narrow perspective on SUT, stressing politically correct priorities or lacking insights into how the treatment goals may be reached, thus also supporting questionable reforms. This critical position seems fairly common across organizations, but most pronounced among interviewees without a management role. The small and traditional municipality NPM-1 is possibly an exception where the social workers report that with support from bosses and the law they can impact on the decision by politicians. A general concern in all municipalities but the rich NPM-6 was that the political board rarely declined treatment in individual cases presented to the politicians, but rather imposed overarching budget cuts or restrictions that the staff had to manage.

In all municipalities citizens could receive a few (3–5) substance use consultations without registration – i.e. a low threshold service developed to attract persons who want to avoid the stigma of being registered by the social services. For some interviewees, such ‘free utility’ services and consumer orientation were as a phenomenon linked to a purchaser-provider system, which by separating various branches of the municipal activities moves the focus towards treatment in a clinical sense. Furthermore, in its more developed form, NPM-systems view the citizens as active service consumers, in contrast to the more paternalistic view of the welfare state, with its control focus. This change of perspective was described for instance in NPM-2, with the reform separating statutory work and treatment and introducing anonymous service. In NPM-5, one interviewee hoped that moving away from the internal market would not endanger anonymous consultations.

Several other NPM-related features were criticized in relation to accessibility and equality of service. Both group heads and staff complain that procurement did not involve treatment experienced staff, or clients, and that this was one of the reasons why frame agreements or purchased services did not provide services for all groups and resulted in unnecessary and abrupt provider changes. Critique in this respect was mainly voiced in the most NPM-permeated NPM-4–NPM-6. Frame agreements were criticized for hindering individualized solutions, prescribing a standardized ranking of institutions, and for being one-sided: ‘too much 12-step, nothing for women, nothing for co-morbidity’ (NPM-5, St). Furthermore, even if the municipality wanted a diverse palette of services in the frame agreement, they did not always get bids from especially sought-after providers. Direct procurement is a way to individualize treatment and go beyond the frame agreement, but it is unpopular in all municipalities, as it is demands extra efforts from the social worker and administration.

Worry was raised in all municipalities but NPM-1 about increasing problems to provide those with complex or severe social problems with adequate support. Services have become ‘more transparent, more clear-cut, but also squarer’ (NPM-4, OP). ‘Personal support is in risk of disappearing’ with the upcoming reform (NPM-2, Stat). ‘We provide more quick treatment, more inhouse [outpatient care], but we need also residential treatment’ (NPM-2, OP). Outreach activities were called for in NPM-4 and NPM-6. ‘Everybody does not manage to come on agreed times’ (NPM-4, Stat). There is too little supported housing in NPM-3 and NPM-5, and we ‘need shelters, people sleep in the streets’ (NPM-5, Stat). It is difficult to get residential treatment. NPM-6 is a notable exception, where in contrast outpatient treatment was regarded as insufficiently developed – in conflict with the goal to get the most out of tax money (NPM-6, Stat).

In the two most NPM influenced municipalities, emphasizing user orientation and choice and with seemingly the most complicated organizations, the problems to provide services for vulnerable groups were most striking and regarded as linked to an ideology emphasizing citizens’ responsibilities. ‘For some people we need interventions and support to enable a worthy life, with relapse … Some people cannot take responsibility for their own life’ (NPM-6, OP). In a system with many branches involved in handling one person’s problems, it can be difficult for those with complex needs to find their way in the system. A far driven digitalization of services can be an obstacle for many clients (NPM-6, Stat). The abrupt change of non-public providers in NPM-5 was considered particularly troublesome for the most vulnerable groups that could require years before they started to trust the staff.

Still, as pointed out in several interviews, equity in treatment is not solely dependent on the organization – it is much dependent on the financial resources of municipal SUT.

Autonomy of social workers

As concerns experiences of sufficient autonomy to make professional decisions, and whether that is restricted by reforms, a general view across municipalities is that social work over time has become more structured, by increasing specialization, more demands regarding methods, structured assessments, more evaluations or recording and sharing of the flow of client work – i.e. standardization, and increased documentation and auditing. The increased structure is not viewed by everyone as only bad, even if it implies ‘more and more elaborate assessments, less treatment’ (NPM-1, OP) and ‘we are often very strictly steered, to tell the truth’ (NPM-2, Stat.) ‘Over time we have been more and more controlled, put in a corner, with evidence, control, evaluations’ (NPM-4, OP). Several interviewees (e.g. in NPM-3 and NPM-5) actually appreciate structure: it is good for provision, and it gives an overview of your work. Social workers also enjoyed their flexible working hours.

These new routines require a significant share of the working hours. ‘Documentation takes 50% of my time’ (NPM-3, Stat). ‘The work is [now] more demanding with practical routines, complicated technique … too much documentation’ (NPM-6, St). The introduction of new routines requires time-consuming learning: ‘One [new] routine can be presented in 35 pages’ (NPM-3, St). With a shortage of staff, documentation can be a special challenge.

The motivations for documentation vary: ‘We try to develop it for unification and protection of citizens’ rights, rule of law’ (NPM-4, Stat), but although ‘documentation is important for clients, as a method, to create a context, I am not very motivated … One follows up the wrong things’ (NPM-4, OP). ‘We measure a lot of things that have no added value for the clients’ (NPM-3, OP).

Among statutory social workers, for most interviewees it is clear and seems often natural that they are working in politically governed organizations and that the work with clients is restricted by political and economic frames. ‘I am not restricted in my assessments, but must think cost efficiently’ (NPM-4, Stat). ‘You can plan your hours, but the law and the leadership give the frame’ (NPM-5, Stat). Younger and less experienced staff seem to have less authority and thus less autonomy: ‘Maybe after 10 years I will have authority’ (NPM-2, Stat, young).

On the contrary, outpatient staff seems to feel less controlled in their daily work, irrespective of the organization. ‘The clients’ needs are decisive, and my own experience, I can modify the methods’ (NPM-5, OP). In NPM-2 and NPM-4, the outpatient staff mentioned that they cannot choose which clients they get. They must admit those assessed and referred by statutory social work.

In the small NPM-1, with good co-operation and few reported organizational problems, it was nonproblematic to cross organizational boundaries if required. Also in NPM-3 and NPM-4, staff was satisfied with the nearest leadership and colleagues that assisted in assessments and decisions. It is only in municipalities NPM-5 and NPM-6 and among statutory workers (and in NPM-2 with the up-coming criticized reform), where we recorded complaints over work climate, cooperation among staff and leadership: in NPM-5 this was combined with complaints over work load.

Discussion

This empirical article confirms several problems and pros associated with NPM reforms in other social work areas. It adds to the literature by scrutinizing the understudied area of SUT (Storbjörk and Stenius 2019b), and by offering insights into the still uncharted post-NPM reforms (Reiter and Klenk 2019) from professionals’ points of view. The study used an extensive and organizationally diverse interview material to analyse the extent to which specific aspects of NPM, in relation to other organizational features, present challenges to daily practices and professional discretion. The current organizational frame shows several problematic features from the point of view of good treatment and related system features (Babor et al. 2008).

Some problems are fairly common for all types of bigger organizations, including traditional welfare models, such as the lack of resources, fragmentation due to internal specialization, and the need for more cooperation between different branches and with external providers (e.g. medical SUT, contracted private providers). Such problems may escalate with but do not necessarily depend upon NPM.

Other problems, more or less common across the municipalities, refer to the top-down and nationally enforced projects aiming at rationalization and control of staff (Hanssen et al. 2015; Lauri 2016) – e.g. trends of EBP, auditing and standardizations – that are highly intertwined with NPM. Concerning social workers’ autonomy, Lauri’s (2016) critical interpretation is that ‘the social work regime of today works to produce a subject who rigidly follow the rules with blind faith as opposed to employing a more autonomous and creative approach, which would allow for flexibility and critical discussion’ (245). ‘Actual’ social work and practice-based knowledge become devalued in favour of documentation and measurable practices. Such reports were present also among our social workers, hence indicating an added challenge by NPM that has become common across organizations. Notably, though, some were content with the highly structured work and some, primarily more experienced social workers, felt they could disregard or alter such principles. The fact that statutory social work is exposed to more control and standardization translates into less autonomy, compared to other staff categories (see also Storbjörk 2020). Despite that all professionals may be experiencing curtailed discretion due to these overarching trends, a larger web-survey, part of the overarching research project, detected lower autonomy and more inconsistent demands in more NPM-like local organizations (ibid.).

Another commonality is the frustration over repeated reforms, usually without evaluations of the prevailing situation or involvement of frontline professionals. Our interviews support the idea of inflated beliefs among administrators and politicians in the positive effects of reforms, led by fads more than insights, and a neglect of transaction costs in terms of extra work and potential loss of established cooperative practices. Interestingly, interviewees at all organizational levels favoured the planned reforms aiming at re-integration. They highlighted the importance of good collaboration between and of keeping statutory social work, service provision, and economic support together, without organizational boundaries. Such post-NPM reforms, originating in a shared understanding of the fragmentation caused by a longer period of NPM, may thereby serve as a blueprint for future reforms to be further evaluated.

NPM organizations do not seem, in the long run, to produce more economical use of resources, but add to the commonly shared difficulties to produce holistic multi-agency services with continuity for all citizens (Lauri 2016; Nesvåg and Lie 2010; Pierre and Peters 2017). The added problems seem to particularly hit less resourced service users. On the other hand, persons with milder social situations and substance use can benefit from choice and anonymous services, by some linked to NPM.

What is most obvious from the study is that NPM in the form of competition and highly split responsibilities and tasks add challenges and appear destructive for SUT quality. Competition and cost control as a route to development and efficient treatment is not refuted, and neither, in general terms, the role of private providers (in line also with post-NPM). But when competition is driven primarily by expectations that it will automatically lead to savings, without sufficient consideration of the population treatment needs, or when the market is characterized by profit chasing, without enough consideration of the service quality, the consequences will be problematic. Such competition increases discontinuity, threatens the necessary trust within the treatment organization and adds to the administration and stress for staff (Pierre and Peters 2017). By narrowing the concept of treatment and designing the system without special considerations for the least resourced problem users, an NPM organization can place the public health aspect out of sight for social services.

The often short and narrow economic perspective of NPM, and the procurement practices combined with naïve beliefs in the positive effects of competition between public and private providers, has in some cases resulted in a waste of resources. The increased critique has questioned the most fundamental belief in NPM solutions within social work (Hanssen et al. 2015; Hjärpe 2017; Lauri 2016). Future post-NPM-reforms, that seem to match social work values better, should therefore properly learn from experience and truly involve both professionals and service users in the necessary reforms aiming at re-integration, improved collaboration, and user empowerment.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplemental material

Supplemental data for this article can be accessed here.

Additional information

Funding

This work was supported by the Bank of Sweden Tercentenary Foundation [Riksbankens Jubileumsfond; RJ; Grant P14-0985:1] and by the Harald and Louse Ekman’s Research Foundation and The Sigtuna Foundation. The funding agencies had no further role in study design, data collection, analysis, interpretations, or the writing of this article.